Physical properties of Scarpa's fascia.

Preservation of Scarpa's fascia has improved clinical outcomes in abdominoplasty procedures and in other body contour surgeries. However, the physical properties of Scarpa's fascia have not yet been described, and grafts are still underexplored. Fresh surgical specimens from five female patients subjected to classical abdominoplasty were dissected and analyzed. A grid was drawn on the fascia surface, dividing it into equal upper and lower halves; four Scarpa's fascia samples (30 × 10 mm) were collected from each half, 40 mm apart. The thickness was measured with a caliper. A strain/stress universal testing machine was used for mechanical tests. Twenty-five samples were obtained (nine from the upper half, 16 from the lower). The average thickness was 0.56 ± 0.11 mm. The average values for stretch, stress, strain, and Young's Modulus were, respectively, 1.436, 4.198 MPa, 43.6%, and 23.14 MPa. The upper half showed significantly greater thickness and strain values (p = 0.020 and p = 0.048; Student's t-test). The physical and biomechanical properties of Scarpa's fascia can make it a donor area for fascial grafts as an alternative to fascia lata, as it is always available and has minimal donor-site morbidity. Further studies are needed to validate this statement. It seems advantageous to use the lower half of the abdomen instead of the upper part as a donor site.

Use of Infrared Thermography for Abdominoplasty Procedures in Patients with Extensive Subcostal Scars: A Preliminary Analysis.

Subcostal scars may increase the risk of healing complications in abdominoplasty. The authors evaluated the use of thermography as a potential tool for patient selection and surgery planning to avoid complications and improve abdominoplasty outcomes. Two candidates for abdominoplasty procedures who presented with extensive subcostal scars were submitted to an infrared thermography protocol at all phases of the procedure: preoperative, intraoperative, and postoperative at 1 and 6 months. The preoperative thermography for both patients revealed near-normal abdominal wall perfusion. The thermograms captured intraoperatively during flap elevation did not show perfusion deficits on the upper abdominal flap. At 1 month and 6 months postoperative, dynamic thermography for both patients showed normal to near-normal perfusion. The procedures had a complication-free course with a good aesthetic result. Plastic surgeons may be reluctant to perform a full abdominoplasty in patients with a previous subcostal incision. In this preliminary analysis, we raise the potential usefulness of thermography for patients with recent subcostal scars and/or important comorbidities as a strategy for adequate patient and technique selection, avoiding possible complications. Future studies, with an increased number of patients and adequate statistical analysis, may allow us to validate the utility of thermography in these cases and reassure that the presence of previous extensive subcostal scars may not be a contraindication for a full abdominoplasty, especially if they are not recent.

Classic Versus Scarpa-sparing abdominoplasty: An infrared thermographic comparative analysis.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to have several clinical advantages. The mechanisms behind its efficiency have been the subject of several studies. Three theories have been proposed, relating to mechanical factors, lymphatic preservation, and improved vascularization. This study aimed to further investigate the possible vascular impact of Scarpa fascia preservation by using a thermographic analysis. METHODS: A single-center prospective study was conducted, involving 12 female patients randomly and equally assigned to one of two surgical procedures: classic (Group A) and Scarpa-sparing abdominoplasty (Group B). Dynamic thermography was applied before and after surgery (one and six months), and two regions of interest (ROIs) were considered. The latter had the same location on every sample, and corresponded to areas where different surgical planes had been used. Static thermography was applied intraoperatively, and four ROIs were considered, located over Scarpa and over the deep fascia. The respective thermal data were analyzed. RESULTS: The general characteristics of both groups were identical. Preoperative thermography demonstrated no differences between groups. Intraoperative higher thermal gradients between lateral and medial ROIs were observed in Group B (P = 0.037, right side). Dynamic thermography at one month demonstrated a trend for better thermal recovery and better thermal symmetry (P = 0.035, 1-min mark) in Group B. No other differences were found. CONCLUSION: Dynamic thermography presented a better response when Scarpa fascia was preserved: stronger, faster, and more symmetric. Based on these results, improved vascularization may have a role in explaining the clinical efficiency of a Scarpa-sparing abdominoplasty.

Effect of the surface finish on the mechanical properties and cellular adhesion in (Ce,Y)-TZP/Al2O3 ceramic composites for denture implants.

Ceramic composites based on (Ce, Y)-TZP/Al2O3 system have great potential for applications as dental implants due to their unusually great balance between good mechanical properties and resistance to hydrothermal degradation. Surface roughness plays an important role in controlling these properties, but few studies have investigated the relationship between cytocompatibility and surface roughness, at levels considered moderate and low, comparable to titanium implants. In this work, bending strength, hydrothermal degradation and biological evaluation of a ceramic composite based on (Ce,Y)-TZP/Al2O3 system were investigated as a function of surface roughness. Compacted samples were sintered at 1500 °C - 2h and then submitted to different surface treatments: Group 1 composed of samples with smooth surfaces, Group 2 and Group 3 composed of rough surfaces (grinded with 15 µm or 45 µm diamond sandpaper, respectively. Samples were characterized by X-ray diffraction, scanning electron microscopy, contact angle and optical profilometry and then subjected to hydrothermal degradation tests in autoclave (134 °C - 2 bar) using artificial saliva. The Piston-on-three-balls (P-3B) testing was used to determine flexural strength. To assess indirect cytotoxicity, samples were immersed in the culture medium for NIH-3T3 cells for 72 h. Furthermore, cell adhesion and proliferation were investigated using MG63 cells (human osteosarcoma) after 3, 7, 14, and 21 days of culture. Cytotoxicity, adhesion, and cell proliferation were examined by the Methyl Tetrazolium salt (MTS) and Alizarin Red, using a confocal laser microscope. The results indicated that the materials have high resistance to degradation. Furthermore, the (Ce,Y)-TZP/Al2O3 composites are not cytotoxic. The flexural strength of the composites was 913 ± 103 MPa in samples presenting original (smooth) surface, however, a reduction in the order of 17% was observed in samples containing rough surfaces. The rougher samples show the best cellular adhesion and proliferation, leading to the formation of a mineralized matrix after 21 days. These results clearly suggest that the new (Ce,Y)-TZP/Al2O3 brand is strong and highly biocompatible and warrants further study.

Shaved Cartilage Gel Versus Diced Cartilage on Final Dorsal Camouflage: Prospective Study of 200 Patients.

Importance: Diced cartilage (DC) is a reported technique that has been used for dorsal camouflage after reduction rhinoplasty. Nevertheless, there are certain issues regarding its use on nasal dorsum, especially its variable resorption rate and risk of graft distortion or migration, especially in thin-skinned patients. Recently, regenerative medicine protocols have been used to overcome drawbacks of methods based on DC. Thus, cartilage embedded in platelet-rich fibrin (PRF) has been described as a promising and reliable alternative to existing procedures. Objective: To compare long-term aesthetic outcomes of two different techniques for dorsal camouflage: DC versus shaved cartilage plus platelet-rich fibrin (SC+PRF)-shaved cartilage gel. Design, Setting, and Participants: This is a prospective, interventional, and longitudinal study at an academic tertiary medical center. Participants were 200 consecutive patients undergoing primary reduction rhinoplasty by spare roof technique (SRT) or component dorsal reduction (CDR). Materials and Methods: The inclusion criteria were primary rhinoplasty, in Caucasian patients with dorsal hump, and camouflage of the dorsum by DC or SC+PRF. Exclusion criteria were ≤18 years of age, revision rhinoplasty and reconstructive rhinoplasty for neoplasic or severe traumatic nasal deformities. The "Utrecht Questionnaire for outcome assessment in aesthetic rhinoplasty" was used. Patients answered it before and after surgery (3 and 12 months after). Results: The study population included 200 patients divided into two groups considering the type of dorsal camouflage: DC (n = 132) and shaved cartilage gel (n = 68). The mean age at the time of surgery was 35.44 years (standard deviation ±9.78) and the study population included 130 females (65.0%) and 70 males (35.0%). Regarding aesthetic outcomes, analyses of postoperative means showed a significant improvement, in both groups, over time. However, self-assessment, based on the visual analogue scale (VAS), at 12 months postsurgery, was higher for patients with SC+PRF than with DC (p = 0.004). Twelve months after surgery, patients with thin skin had better aesthetic outcome with SC+PRF than with DC (p = 0.001). For both reduction rhinoplasty techniques, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (SRT: p = 0.016; CDR: p = 0.004). For both rhinoplasty approaches, either open or closed, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (closed approach: p = 0.046; open approach: p = 0.017). Conclusions: SC+PRF provides better long-term aesthetic outcomes, not only for thin-skinned patients, but also for patients who had undergone rhinoplasty by a structured or preservation technique, or by an open or closed approach, for dorsal hump reduction.

Spare Roof Technique Versus Component Dorsal Hump Reduction: A Randomized Prospective Study in 250 Primary Rhinoplasties, Aesthetic and Functional Outcomes.

BACKGROUND: Most Caucasian aesthetic rhinoplasty patients complain about having a noticeable hump in profile view. Taking the integrity of the middle vault into consideration, there are 2 ways to dehump a nose: the structured technique and the preservation technique. OBJECTIVES: The aim of this study was to compare the aesthetic and functional outcomes of 2 reduction rhinoplasty techniques. METHODS: We performed a prospective, randomized, interventional, and longitudinal study on 250 patients randomly divided into 2 groups: the component dorsal hump reduction group (CDRg) (n = 125) and the spare roof technique group (SRTg) (n = 125). We utilized the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty. Patients answered the questionnaire before the surgery, and at 3 and 12 months after surgery. In addition, we utilized a visual analog scale (VAS) to score nasal patency for each side. RESULTS: Analyses of the preoperative and postoperative aesthetic VAS scores showed a significant improvement in both groups, from 3.66 to 7.00 (at 3 months) to 7.35 (at 12 months) in the CDRg, and from 3.81 to 8.14 (at 3 months) to 8.45 (at 12 months) in the SRTg. Analyses of postoperative means of aesthetic VAS scores showed a significant improvement in both groups over time. However, aesthetic improvement was higher in the SRTg than in the CDRg at both 3 (P < 0.001) and 12 months (P < 0.001) postsurgery. Analyses of the mean functional VAS scores showed a significant improvement with both techniques, with a better result for the SRTg. CONCLUSIONS: The SRT is a reliable technique that can help deliver consistently better aesthetic and functional results than CDR for reduction rhinoplasty in Caucasian patients with a dorsal hump.

99mTc-antitumor necrosis factor-alpha scintigraphy for the detection of inflammatory activity in rheumatoid arthritis.

OBJECTIVE: Tumor necrosis factor-alpha (TNF-α) is an important inflammatory cytokine. 99mTc-anti-TNF-α antibody scintigraphy has proven to be a viable alternative to MRI in specific cases. The objective of this study was to evaluate the performance of scintigraphy with 99mTc-anti-TNF-α in the identification of inflammatory foci in individuals diagnosed with rheumatoid arthritis using MRI as the gold standard. METHODS: This cross-sectional, descriptive and analytical-qualitative clinical study compared the performance of 99mTc-anti-TNF-α scintigraphy with that of MRI with intravenous administration of gadolinium (used as the gold standard) and a clinical examination (Disease Activity Score 28) in 220 joints of 20 patients with a diagnosis of rheumatoid arthritis and one healthy control. RESULTS: The concordance of scintigraphy with MRI in individuals with a diagnosis of rheumatoid arthritis was 79%. The accuracy, sensitivity and specificity of scintigraphy for distinguishing between inflammatory and noninflammatory sites were 92, 89, and 93%, respectively. No adverse reactions to the examinations were reported. CONCLUSIONS: Scintigraphy with 99mTc-anti-TNF-α was well-tolerated and had a good ability to distinguish between inflammatory and noninflammatory lesions in patients with rheumatoid arthritis.

Spare Roof Technique: A New Technique for Hump Removal-The Step-by-Step Guide.

Humpectomy is one of the most common steps in reduction rhinoplasty among Caucasian patients. The most widespread procedures to address hump removal are both the "en bloc humpectomy" (with reconstruction of the middle third with spreader grafts) and the "split hump technique" (with confection of spreader flaps). The spare roof technique, for rhinoplasty reduction, has been developed over the past 4 years. In this technique, the upper lateral cartilages are completely preserved-even the hidden part under the caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper lateral cartilages are released from the dorsal aspect of the nasal septum; step 2, a 1-mm strip of the dorsal septum is taken in each movement as required; step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral cartilages intact and releasing the "lateral" (left and right) pyriform aperture ligament; step 4, classic medial and lateral osteotomies (closing the open bony roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and thus avoiding the natural spring effect. The outcomes of the first 100 patients have been validated by a prospective, interventional, and longitudinal study performed on patients undergoing primary rhinoplasty by means of the spare roof technique. This study confirms that the spare roof technique significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in Caucasian and Mediterranean patients with a dorsal hump seeking rhinoplasty.

Dorsal Hump Reduction Based on the New Ethmoidal Point Classification: A Clinical and Radiological Study of the Keystone Area in 138 Patients.

BACKGROUND: Hump resection often requires reorganization of the keystone area. OBJECTIVES: The authors sought to describe the importance of the point where the perpendicular plate of ethmoid joins the septal cartilage (SC) and the nasal bones (NB) (Ethmoidal point [E-point]) for hump resection surgical planning. METHODS: Measurements from mid-sagittal slices in nasal computed tomography scans taken in adult Caucasian patients between January 2015 and December 2018 were compared between patients seeking primary rhinoplasty due to a nasal hump and patients not seeking rhinoplasty (control group). Patients with previous nasal surgery or trauma, genetic or congenital facial disorders, and high septal deviation were excluded. The length of overlap between NB and SC was compared between the 2 groups. The location of the E-point in relation to the beginning of the nasal hump in the cephalocaudal direction was documented in the patients seeking rhinoplasty. RESULTS: The study population included 138 patients, 69 seeking and 69 not seeking rhinoplasty (96 females). The mean age was 32.9 years (range, 18-55 years). The length of overlap between NB and SC was similar between both groups (11.7 ±â€…3.3 vs 10.8 ±â€…3.3; P = 0.235). The E-point was located before the beginning of the nasal hump in 97% (67/69) of nasal hump patients, and it could be found a mean distance of 2.3 (±2.3) mm cephalic to the latter. CONCLUSIONS: As a rule, the perpendicular plate of the ethmoid does not contribute to the nasal hump; therefore, only in exceptional cases should this be addressed while performing dorsal reduction.

A Prosthodontic Treatment Plan for a Saxophone Player: A Conceptual Approach.

INTRODUCTION: A wind instrumentalist was diagnosed with a periapical lesion on tooth 21. The prosthetic rehabilitation options were considered with respect to the embouchure mechanism of the saxophonist. The underlying mechanism associated with the embouchure of the saxophone player was observed in this particular case in order to understand if asymmetrical forces were transmitted to the upper central incisors. Periapical lesions can be harmful to the oral health of musicians. The treatment options thus have to be taken into consideration with special focus on the need for oral rehabilitation on the anterior maxilla. MATERIAL AND METHODS: The patient underwent a radiographic examination with a panoramic X-ray. Subsequently, two piezoresistive sensors (FlexiForce™) were placed on the upper surface of the mouthpiece in order to quantify the pressure applied to the central incisors during the embouchure. In order to understand the values involved during this procedure, the saxophone player was required to play three different notes at different pitches: high, medium, and low. This procedure was repeated three times for each pitch in order to obtain a medium value for each note. Signal acquisition was obtained within software developed for this purpose, with the voltage output observed in LabView 2011®. RESULTS: The panoramic X-ray showed a periapical lesion with the characteristics of a radicular cyst on tooth 21. The FlexiForce™ piezoresistive sensors allowed us to find that greater force (kg) was being applied to tooth 11 in comparison to tooth 21 during the embouchure mechanism. CONCLUSIONS: The sensors used in this research are acceptable for identifying the tooth where the greatest pressure is applied during the mouthpiece stabilization. In the case of executing an oral rehabilitation procedure for wind instrumentalists, a clinical examination can be complemented with the aid of bioengineering and the inherent development of sensor technology in order to better understand the embouchure mechanism. Likewise, the prosthetic rehabilitation should be taken into consideration in order to provide minimal changes to the musician's performance.

The facial artery perforator flap for intraoral reconstruction of a mouth floor defect.

Facial artery perforator flaps have been recently reported by different authors for perioral, nasal alar and cheek defects, but not for intraoral reconstruction. We have extended the use of the facial artery perforator flap in a 56-year-old man with a squamous cell carcinoma of left mouth floor, who was submitted to tumor resection with marginal mandibulectomy and left supraomohyoid neck dissection. The flap was designed according to the size of the defect (5 × 3 cm), centered on the perforator to create a symmetric flap and was tunnelled intraorally by means of a 90° rotation. The postoperative period was uneventful, allowing timely initiation of adjuvant radiotherapy. After 8 months, there were no signs of local recurrence or wound dehiscence, and functional outcomes were satisfactory. The main advantages of this flap in this case were the reduction in morbidity at the donor site with preservation of nerves, muscles and facial artery, and it allowed greater freedom. To the best of the authors' knowledge, this technique has not been reported before. It may constitute an important reconstructive option when dealing with similar defects, if our results are confirmed in larger series.

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure.

When an auricular defect is caused by high-energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year-old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A "printed" ear made of silicone, based on the patient's CT-scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

Burden of Burns in Brazil from 2000 to 2014: A Nationwide Hospital-Based Study.

BACKGROUND: Burns are a major public health concern, affecting mostly low- and middle-income countries. However, there is a lack of epidemiological studies on burns in these countries, particularly in Latin American countries. Our aim was to analyze nationwide demographic, epidemiological and economic characteristics of hospitalized burn patients in Brazil. METHODS: A retrospective study was conducted including inpatients admitted with a diagnosis of burns (ICD-10:T20-T31) from all hospitals in Brazil from 2000 to 2014. We calculated hospitalization and in-hospital mortality rates. Length of stay (LoS), charges and premature mortality were also assessed. RESULTS: A total of 412,541 burn hospitalizations were found, with a hospitalization rate of 14.56 hospitalizations/100,000 inhabitants/year. This rate is decreasing since 2003, mostly due to the reduction among children and elderly. Children below 5 years old accounted for 24% of all admissions. In-hospital mortality rate was 8.1% and median LoS was 5 days. Mean hospitalization charge was 856 international dollars. Substantial regional discrepancies were found in several indicators. CONCLUSION: In this first Latin American nationwide study of burn patients, a decreasing trend of hospitalization rate and a low charge contrasted with a high in-hospital mortality rate. This latter indicator, associated with a low LoS, may raise concerns regarding the quality of healthcare. Important discrepancies were found between regions, which may indicate important differences in regard to healthcare access and risk of burns. Targeting effective prevention, improving healthcare quality and providing more widespread and accurate burn registry are recommended.

Predictors of satisfaction in patient with silicone breast implants and its association with drug intake habits.

BACKGROUND: Satisfaction is an important outcome variable in surgical success. The purpose of this study is to evaluate predictors of satisfaction in women submitted to silicone textured breast implant surgery. METHODS: A retrospective evaluation of women receiving textured silicone breast implants was performed. Patients were divided in four groups: cosmetic cohort (n = 104), reconstructive cohort (n = 120), general population control cohort (n = 120) and aesthetic control cohort (n = 54). Data were collected based on information retrieved from patient records, a planned consultation and a self-administered structured questionnaire. RESULTS: Patient satisfaction was influenced by preoperative information (p = .007), cohort (p < .001), and occurrence of postoperative complications (p < .001). The degree of satisfaction was also related with drug intake habits: women using psychotropic drugs were 3-fold more likely to report poor satisfaction than those that never used these drugs (p < .001). CONCLUSION: The purpose of the surgery, preoperative information and the occurrence of postoperative complications have an impact on the degree of satisfaction of women submitted to silicone breast implant surgery. Women using psychotropic drugs are more likely to report poor satisfaction.

Abdominoplasty with Scarpa fascia preservation - comparative study in a bariatric population.

BACKGROUND: Abdominoplasty techniques using a more superficial plane of dissection with Scarpa fascia preservation have been shown to improve recovery and reduce complications in nonbariatric patients. Patients who have experienced massive weight loss frequently need body contour procedures and represent a high-risk group. OBJECTIVE: To evaluate the effect of this technique in patients with massive weight loss after bariatric surgery. SETTING: University hospital, Portugal. METHODS: This was a single-center retrospective study of 51 postbariatric patients who had been undergone either a classic full abdominoplasty (group A) or a similar procedure except for the preservation of Scarpa fascia below the umbilicus (group B). General characteristics of both groups were analyzed, and recorded outcomes were total and daily volume of drain output, time until drain removal, time until hospital discharge, and local and systemic complications. RESULTS: There were no statistically significant differences between groups regarding general characteristics or complications. The Scarpa fascia preservation group had a highly significant reduction of 79% on the total drain output, 7 days until drain removal, and 5 days' hospital stay. Long drainers (7 days or more with drains) were eliminated (reduction from 52% in group A to 3% in group B) and seroma had a 65% reduction. CONCLUSION: Preserving Scarpa fascia during a full abdominoplasty in postbariatric patients improves recovery by reducing total drain output and hospital stay, allowing earlier drain removal, eliminating long periods with suction drains, and reducing seroma incidence. Clear benefits for the patient were obtained.

Nine years of a single referral center management of Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell's syndrome).

CONTEXT: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) corresponds to a rare and acute life-threatening mucocutaneous reactions characterized by extensive necrosis and epidermal detachment. There are no efficacious pharmaceutical interventions proven through large clinical trials. OBJECTIVE: We sought to study clinical cases admitted in our institution in order to determine which drugs and medical comorbidities or treatments impacted the mortality. MATERIAL AND METHODS: In a retrospective study over 9 years we evaluated all patients presenting biopsy-proven SJS or TEN for age, gender, total body surface area involved, causing agents, SCORTEN score, blood transfusion, steroid administration, intubation, length of intensive care stay and death rate. Statistical analysis was done using SPSS statistical software. RESULTS: The highest incidence of SJS and TEN was in age group of 71-80 years. Of the 30 patients, 30% died from SJS/TEN, mainly due sepsis. For each subgroup SJS/TEN overlap had the highest mortality. The highest mortality was from antibiotic treatment as causing agent. Step-wise regression analysis identified mechanical ventilation requirement and age over 65 years as mortality high-risk factors. DISCUSSION: The most crucial interventions are discontinuation of the offending drug and prompt referral to a burn unit, which helps in early diagnosis and decrease mortality in these diseases. CONCLUSION: When SJS/TEN is caused by antibiotics suspicion of developing fatal sepsis should be high, independently of patients' medical condition.

Correction of Residual Static and Dynamic Labial Deviations in a Paralyzed Face After Free Gracilis Muscle Transplantation.

Free muscle flap transfer is currently the procedure of choice for longstanding facial paralysis to restore symmetry both at rest and when smiling. However, movements obtained are generally localized, unidirectional, and philtrum centralization and lower lip movement is not proportionally achieved. The stability of free flap insertion at the lips also interferes with the results, as gradual disinsertion and shifting of the nasolabial fold can be caused by repetitive movements. Asymmetry of smile can also be caused by lip depressor inactivity due to marginal mandibular paralysis, and both dynamic and static procedures are often required after dynamic reanimation. Here, the authors report a technical refinement that can be used even years after facial reanimation, using concealed scars and with minimal morbidity for correction of static and dynamic labial deviations from the midline. Placement of a transfixed tendon graft in C-fashion tendon graft between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side allows the forces from muscle contraction to be transferred to the philtrum and lower lip. It allows correction of static and dynamic labial deviations from the midline, reducing rates of inadequate fixation and partial or total disinsertion of the muscle flap in the buccal region.

The Free-style Gluteal Perforator Flap in the Thinning and Delay Process for Perineal Reconstruction After Necrotizing Fasciitis.

Perineal wounds present a special challenge for reconstructive surgeons. The vacuum-assisted closure device is useful as a temporizing measure or for wounds too large or contaminated for immediate reconstruction. Compared to traditional myocutaneous flaps, perforator flaps provide thinner fasciocutaneous flaps for perineal reconstruction with favorable results and fewer donor site morbidities. The upper and lower gluteal regions are rich in perforators, which allow for more versatile flap design according to the defect. The authors combined the principles of free-style perforator flaps, flap delay, and thinning of perforator flaps to restore perineal function and aesthetics. The procedure was undertaken in a 72-year-old female who was obese with the diagnosis of necrotizing fasciitis secondary to perineal abscess. After 3 months, the flap achieved adequate and durable reconstruction with acceptable aesthetic contour and patient satisfaction; there was no loss of function at donor sites. Clinical applications and technical refinements of freestyle pedicled perforator flaps can be extended to the perineal region. Because of its many advantages and its versatility, freestyle pedicled perforator flaps constitute a valued reconstructive option and, when indicated, an alternative to pedicled axial flaps or even free flaps, in addition to vacuum therapy, to simplify the reconstructive procedure.

The Freestyle Facial Artery Perforator Flap for Reconstruction of Simultaneous Periorbital and Cheek Defects.

The reconstruction of defects involving the nasolabial, paranasal, and periorbital regions may be challenging, because they often involve more than one facial aesthetic unit, and can lead to functional problems. An average of 5 facial artery perforators of caliber >0.5 mm can be found above the mandible. A reference point for the location of the most constantly encountered perforator was suggested as being 1.5 cm lateral to the oral commissure, and at its same level in height or slightly inferior to the commissure. Based on injection studies, it is known that these perforators can supply an average area of 8 cm. The authors have extended the use of the freestyle perforator flap in a 87-year-old woman presented with an advanced melanoma of the paranasal area and nasolabial region (Breslow depth: 9 mm; Clark level V). Complete resection of the lesion with 3 cm oncological margins was performed. One-stage reconstruction with superior cosmetic results was achieved. The need for a perforator dissection is not necessarily a drawback, and classic concerns should be abandoned. The face is highly vascularized, and flap congestion is a rare event, usually a consequence of excessive pedicle trimming. Although technically more demanding, it should become one of the first reconstructive options when dealing with similar defects, if our results are confirmed in larger series.

Reconstruction of a postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure-A case report.

Radial club hand may be congenital or acquired; radial deviation of the hand is usually found, associated with palmar flexion-pronation and treatment of severe forms of radial club hand is often difficult. Here we present a case of reconstruction of a severe postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure in a 28-year-old man. The patient had a radial deviation of the wrist and right upper limb shortening as a result of an infected pseudarthrosis of the radius. This deformity was reconstructed with a free fibular osteoseptocutaneous flap associated to arthrodesis of the distal radioulnar joint and an ulnar resection osteotomy proximal to the arthrodesis in order to restore rotation of the forearm (Sauvé-Kapandji procedure). The flap fully survived and no complications were seen in the early postoperative period at both recipient and donor sites. Radius alignment was restored. At 5-month follow-up, the skeleton was healed. There was minimal osteopenia at the distal radial segment. Wrist extension was 48 degrees, flexion 24 degrees, and pronation-supination was 58-0-48 degrees, with full finger flexion. The patient could hold a 4 kg dumbbell with the elbow flexed without discomfort. His DASH score-Disabilities of the Arm, Shoulder, and Hand Questionnaire was 15.83. Combined free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure may be considered in severe forms of postraumatic radial club hand, however, further data are necessary. © 2016 Wiley Periodicals, Inc. Microsurgery 36:593-597, 2016.